Ebook Phlebotomy from student to professuonal (3/E): Part 2

(BQ) Part 2 book Phlebotomy from student to professuonal has contents: Collection by skin puncture, special blood collection procedures, urine tests, special considerations, common laboratory tests, communication skills for the phlebotomist, conflict management skills,... and other contents

6 Collection by Skin

Puncture

After studying this unit, it is the responsibility of the learner to be able to:

1 List several situations in which the preferred method of blood collection

4 State the steps in performing a fi ngerstick

5 Demonstrate the appropriate steps in performing a fi ngerstick

6 State the steps to performing a heelstick

“The differences in venous

and skin-puncture blood

should not restrict the use

of skin-puncture blood.”

—National Committee

for Clinical Laboratory

Standards (1986)

capillary blood collection procedure

cyanotic displaying blueness of the skin, as from

imperfectly oxygenated blood

interstitial fl uid fl uid between the tissues

bone, resulting from infection

plantar relating to the sole of the foot

Copyright 2010 Cengage Learning All Rights Reserved May not be copied, scanned, or duplicated, in whole or in part Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

CHOOSING THE SKIN PUNCTURE

In several situations, the skin puncture may be preferable to the venipuncture

These situations may arise when:

The patient is an infant, and a good vein is not found

•

The patient is a small child, and either a proper vein is not found

•

or the child will not cooperate with the venipuncture

Tests are ordered that require only a few drops of blood

A skin puncture is not appropriate when:

The patient is severely dehydrated

S kin puncture, or capillary puncture, is a procedure in which

the skin is punctured with a lancet to obtain a capillary blood sample for laboratory testing While laboratory tests are most often performed on venous blood, there are situations in which venipuncture is not appropriate

COMPOSITION OF SKIN PUNCTURE BLOOD

Skin puncture blood is different in composition from venous blood Blood obtained by skin puncture is a combination of blood from capillaries, arte-rioles, and venules It more closely resembles arterial blood than venous blood Skin puncture blood may be used for laboratory testing so long as the technique is taken into consideration when interpreting the results of blood tests and when a small sample of blood is suffi cient for the tests

As the skin is punctured, tissue is damaged and interstitial fl uid—the fl uid present between tissues—is released The fi rst drop of blood will

be diluted by this and fl uid will need to be wiped away

SITE SELECTION

A skin puncture (also called a capillary puncture) may also be performed

on fi ngertips, heels, toes, or earlobes However, the earlobe is not mended as a site of choice, due to poor capillary access

recom-Children and Adults

Generally, the site of choice is the portion of the fingertip shown in Figure 6-1 Do not puncture the side or the tip of the fi nger The ring

fi nger and the middle fi nger are the appropriate fi ngers for puncture

Figure 6-1 Finger puncture site.

This Not this

The thumb, fi rst fi nger, and fi fth fi nger are not appropriate choices for skin puncture The tissue on the fi fth fi nger is much thinner than on the other fi ngers The thumb and fi rst fi nger are usually calloused The nondonimant hand may be a better fi rst option since the fi ngers may be less calloused Patients requiring frequent fi ngersticks—such as for glu-cose monitoring, for example—should have the puncture site rotated

The puncture should be made perpendicular to the fi ngerprint A pendicular puncture will cause the blood to form a droplet A parallel puncture will cause the blood to fl ow down the fi nger instead of forming

per-a nice round drop

Edematous (swollen) sites should be avoided, because a free fl ow of blood is impossible Punctures in cold, or cyanotic, areas should also be avoided Blood obtained from these sites may result in falsely high hemo-globin or cell-count values

Infants

The site of choice is the lateral (side) area of the plantar surface of the heel (“plantar” refers to the sole of the foot) The darkened areas

in Figure 6-2 show the preferred areas in which to perform a

heel-stick Never use the area of the heel bone as a puncture site In tion, never puncture the area of the arch Puncturing either of these

addi-areas may have serious consequences for the infant Puncturing the heel bone may result in infection and osteomyelitis, an infl ammatory disease of the bone Puncturing the arch area may cause damage to

nerves Never perform a puncture that will go through a previous site

Never perform a skin puncture on the fi nger of an infant The tissue

on an infant’s fi nger is much too thin, and the procedure could damage the bone

Figure 6-2 Heel puncture site.

A

PREPARING THE SITE

A free fl ow of blood is important for accurate test results Massaging the

fi nger of the adult or child and the heel of the infant until the skin is pink will stimulate circulation Warming the skin will also increase blood fl ow

A wet towel (or a packaged heating product) comfortably warmed to the touch may be applied to an adult’s or child’s fi nger or to the heel of an infant The heat source should be applied for at least 3 minutes

COLLECTION DEVICES

A wide variety of devices are now used to collect, process, and transport blood obtained from a skin puncture Traditionally, blood is obtained with disposable capillary pipettes that resemble plastic straws The blood fl ows into the tube through capillary action

The process of collecting skin puncture blood has been simplifi ed by the introduction of different types of microcollection devices Figure 6-3 shows two such devices These collection devices allow for easier measuring, color coding, stoppering, centrifugation, and storage of the blood samples

Collection caps, often shaped like a scoop, are used to collect the blood

Figure 6-3 Microcollection devices.

A good fl ow of blood is obtained with the correct use of the skin puncture device As with the collection devices, a wide variety of skin puncture lan-cets are available

Lancets are designed to control the depth of the puncture so that no damage will be done to the site Most lancets are either blades that the phlebotomist pushes into the skin or spring-loaded devices that lie on the surface of the skin and make an automatic puncture The spring-loaded devices have a button that, when pressed, releases the lancet into the skin

Patients may be less frightened by this device, because they cannot see the actual blade penetrate the skin

4 Select a puncture site

5 Massage or warm the puncture site The heel may be warmed with a warm cloth not to exceed 42ºC (107ºF) Commercial infant heel warmers are also available

6 Put on gloves to prevent exposure to bloodborne pathogens

7 Cleanse the fi ngertip with the alcohol prep pad to prevent microbiological contamination of the patient and the specimen

8 Dry the fi ngertip to prevent hemolysis of the specimen from sure to alcohol, and to reduce a stinging sensation for the patient

9 Remove cover from lancet or other device to be used

fi ngernail Wrap your fi ngers around the inside of the patient’s

fi nger This maintains your control of the patient’s fi nger while allowing you the best access to the puncture site

lancet to fi rmly puncture the skin One fi rm and quick puncture

is less painful than a repeated puncture because of inadequate

penetration Many beginners bounce the lancet off the fi nger instead of achieving penetration.

acci-dental puncture by the lancet

drop of blood

contains interstitial fl uid that could dilute the sample

device(s)

platelet clumping in the collection device Gently tap the EDTA tube periodically to mix the blood with the anticoagulant If

fi lling capillary tubes or microhematocrit tubes, fi ll the tube approximately 2/3 full and seal with the appropriate sealing com-pound These tubes may be labeled by wrapping a label around all of them and placing them into a nonadditive collection tube

Label the collection tube with the appropriate label information

“milk” the patient’s fi nger by fi rmly sliding your hand grasp back toward the patient’s fi ngernail

of the specimen with interstitial fl uid Allow the blood to fl ow freely into the tube Do not “scoop” the blood into the collection tube Doing so forces tissue fl uids into the specimen

dry piece of gauze over the puncture site Have the patient apply pressure until the bleeding has stopped Do not use a bandage

on the fi nger of a toddler Young children may swallow small bandages and choke

prevents clotting of the specimen

in a biohazard container

ensure identifi cation of specimen

prevent contamination of the patient area

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ORDER OF DRAW FOR SKIN PUNCTURE

1 Slide for differential or stain

2 Blood gas or pH specimen

3 Hematology specimens (EDTA tubes)

4 Chemistry or other specimens (additive tubes fi rst, then ditive tubes)

nonad-PERFORMING A HEELSTICK

Performing heelsticks on infants requires extra care and attention (Please refer to Figure 6-4.) Selecting the appropriate puncture site is extremely important Caution should be taken when applying pressure to the infant’s foot Do not puncture bruised areas or previous puncture sites

Collecting blood samples in the hospital nursery requires the use of isolation techniques Never take a collection tray into the nursery Wash your hands thoroughly This procedure may take as long as 3 minutes

Follow the instructions carefully for proper hand washing before entering

a nursery

Put on a long-sleeved gown and a mask, if required Follow all

nurs-ery protocols for interacting with infants

Figure 6-4 Performing a heelstick.

1 Identify the infant.

2 Assemble supplies Heelstick and fi ngerstick supplies are similar

However, a short-point lancet of less than 2.4 mm must be used for the heelstick A puncture of more than 2.4 mm may cause bone damage Open the gauze, alcohol prep, and lancet pack-ages, but leave items inside the packages

3 Put on gloves

4 Warm and/or gently massage the heel

5 Select an appropriate puncture site, avoiding previous puncture sites and the curvature of the heel

6 Grasp the infant’s foot fi rmly A fi rm hold will help prevent sudden movement Place your forefi nger over the arch of the baby’s foot and your thumb below the puncture site Your remain-ing fi ngers should rest on top of the infant’s foot The baby’s foot will be resting between your index fi nger and your third fi nger

7 Cleanse the area with an alcohol prep

8 Dry the site with clean gauze

9 Puncture the skin in a quick, fi rm, down-and-up motion

Remember that the puncture should be perpendicular to the heelprint lines

tissue fl uid

samples fi rst

the infant’s foot, place a clean gauze over the puncture site, and press fi rmly until bleeding stops

another heelstick, which should be avoided in any way possible

Skin punctures, whether fi ngersticks or heelsticks, require much practice

Often the phlebotomist will be performing a skin puncture because the patient is compromised in some way Skin punctures can be very painful for the patient, as well as time-consuming Proper technique will minimize patient trauma, realize a good result, and take a short amount of time

Drawing blood from infants takes much experience Obtaining blood from a newborn in the nursery can be a very exacting task Nurseries have strict rules to guard the babies from infection The phlebotomist must be very careful to obtain the specimen without trauma to the baby’s foot, and

to collect a specimen that will give accurate results

[ A L E R T ]

The phlebotomist must always use a short-point lancet on a baby’s heel A puncture of more than 2.4 mm may cause bone damage

2 List two situations in which a skin puncture would not be proper.

a

b

3 Skin puncture blood more closely resembles

blood than venous blood

4 Capillary punctures may be performed on ,

1 An adult outpatient needs to have a CBC collected The patient

is very frightened about having his blood drawn He has a good vein on his right arm, but he refuses to let you draw from it

He states that he is in a hurry, and must get back to work What should you do?

2 An 18-month-old child needs a CBC and blood culture drawn

You attempt a venipuncture, and are able to obtain only enough blood for the blood culture The CBC is stat What are your options?

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7 Special Blood

Collection Procedures

After studying this unit, it is the responsibility of the learner to be able to:

1 Describe the procedure for performing a PKU test

2 State the normal range values for PKU and bleeding times

3 List the steps in performing a glucose tolerance test

4 State the purpose of blood cultures

5 List the steps in the collection of blood cultures

“The basis of medicine is

sympathy and the desire to

help others, and whatever is

done with this end must be

called medicine.”

—Frank Payne

etiology the science and study of diseases and

their causes and origins

hemostasis cessation of bleeding through the

blood coagulation process

insulin hormone that regulates the metabolism

of glucose

children and for the metabolism of protein

septicemia the presence in the bloodstream of infectious microorganisms or their toxins

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NEWBORN SCREENING

The purpose of routine newborn screening is to diagnose shortly after birth those infants with metabolic disorders for which early treatment will prevent or minimize serious, irreversible complications such as mental retardation Newborn screening is cost-effective within the health care system, and can screen infants on a large scale The tests that comprise the battery may vary from state to state However, phenylketonuria and hypothyroidism testing are required in all states These tests require blood collected from a heelstick onto fi lter paper

Phenylketonuria (PKU) Screening

PKU is an inherited disorder of body chemistry that, if untreated, causes mental retardation About one baby in 15,000 is born with PKU in the United States The disorder occurs in all ethnic groups, but is most com-mon in people of northern European descent

PKU is a disease that affects the way the body processes food Babies with PKU can’t process an amino acid called phenylalanine, which is necessary for metabolizing protein The phenylalanine builds up in the bloodstream and causes brain damage and mental retardation

PKU was first recognized in 1934 by a mother of two mentally retarded children She became aware that the urine of the children had an odd odor, and on the basis of this was able to have a biochemist,

Dr Asbjorn Folling, study the urine and identify phenylpyruvic acid

A test developed in the 1960s by the March of Dimes is used to screen for PKU A blood specimen should be obtained from every neonate before the baby is discharged or transferred from the nursery Any premature infant should have a specimen obtained for screening at or near the sev-enth day of age Premature infants, infants weighing less than 11 kg (5 lb),

S pecial procedures are necessary to collect blood samples for

unique tests Tests covered in this chapter are newborn screening, blood cultures, glucose testing, and bleeding times

may have elevated phenylalanine and tyrosine levels without having the genetic disease This is probably a result of delayed development of appro-priate enzyme activity in the liver The test is highly accurate when per-formed when the baby is more than 24 hours but not more than 7 days of age The child has to have a chance to ingest protein (mild) for a period of

24 hours All states now routinely screen newborns for PKU

Mental retardation can be prevented if the baby is treated with a cial diet that is low in phenylalanine beginning before the fourth week

spe-of life In a positive test for PKU, the blood phenylalanine is greater than

15 mg/100 mL Testing should continue throughout an adult’s life, and a diet low in protein maintained

Hypothyroidism

Hypothyroidism results from an inadequate supply of the thyroid mone, thyroxine Approximately one out of every 4,000 newborn infants has hypothyroidism Untreated, the child’s growth will be stunted, and mental retardation will occur from lack of stimulation of the brain by the hormone thyroxine Testing for hypothyroidism uses the same fi lter paper blood spots as for PKU screening The condition is treated by utilizing thyroid hormone replacement treatment as soon as possible after birth

hor-P R O C E D U R E

P R O C E D U R E N e w b o r n S cre e n i n g Pr o ce d u re fo r Fi l t e r

Pa p e r C o l l e c t i o n

1 Identify the baby

2 Complete information on the specimen collection kit Do not touch the area within the circles on the fi lter paper

6 Cleanse the heel with alcohol swab

7 Air-dry the site, or wipe with dry sterile gauze

8 Hold the infant’s leg in a position lower than the heart

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9 Puncture the heel with an automated lancet device to a depth

of no more than 2.4 mm on the plantar surface of the heel

(See Figure 7-1A.)

circle A suffi cient amount of blood should soak through to fi ll the circle Apply blood to only one side of the paper Ensure that the blood has penetrated and saturated the paper Do not layer successive drops of blood on the circle spot Do not touch the blood spot

drop of blood Fill each circle Do not squeeze the puncture

Doing so may cause hemolysis of the specimen and add tissue

fl uids to the specimen

a sterile gauze against the puncture site Please refer to Figure 7-1B

away from direct sunlight Do not stack or touch other surfaces

to the fi lter paper during the drying process

Figure 7-1 Heelstick procedure for newborn screening (A) Appropriate puncture site (B) Apply drops of

blood to circle on newborn screening card.

BLOOD CULTURES

Blood cultures are ordered by physicians to rule out or confirm

blood-stream This condition can lead to the death of a patient

The correct collection of blood cultures is extremely important

Because the results of these cultures lead to the identification of the condition’s origin, or etiology, the phlebotomist plays a very signifi cant role in ensuring the accuracy of this important test

Blood cultures are usually ordered just before the beginning of microbial therapy in a series of three draws The cultures are collected in

anti-a series of three becanti-ause thanti-at manti-akes it more likely thanti-at the organti-anism will

be detected In some cases it may be possible that the septicemia is caused

by a localized infection If this is suspected, the physician will order the series to be collected all at one time but from three different sites, rather than at three different times

Blood cultures are drawn in sets of two bottles One bottle is the

second bottle is called an anaerobic bottle for microorganisms requiring the absence of oxygen to grow Please refer to Figure 7-2

P R O C E D U R E Pr o ce d u re fo r B l o o d C u l t u re C o l l e c t i o n

1 Identify the patient

2 Select a site, and follow routine venipuncture procedure

Venipuncture sites do have an effect on the contamination rate among blood cultures The antecubital vein is less likely to pro-duce a contaminated specimen than the umbilical or femoral

Figure 7-2 Blood culture collection procedure (A) Assemble blood culture collection supplies (B) Prep

venipuncture site with povidone-iodine in circular motion (C) Perform venipuncture.

vein Also, indwelling intravascular catheters are poor sources for blood culture collections These lines become colonized with bacteria when left in place for longer than 48 hours If a blood culture is obtained from an indwelling line, the femoral vein, or the umbilical vein, the source must be documented to ensure proper interpretation of test results.

3 Assemble the necessary equipment: culture bottles, commercial prep kit, alcohol preps, syringes, needles, gauze, tourniquet, gloves (refer to Figure 7-2A)

4 Reject any damaged or deteriorated culture vials

5 Prepare the container(s) Swab the rubber stopper or diaphragm top of the culture bottle(s) with an antiseptic agent (iodine is not recommended for swabbing a rubber stopper) The stoppers may be contaminated and must be aseptically prepped

6 Put on gloves

7 Prep the venipuncture site To aseptically prep a venipuncture site, 1 to 2 minutes must be allowed for the agent to have any effect Scrub a 3- to 4-inch-square area for 2 minutes with a commercially prepared prep kit (Figure 7-2B) Allow the site

to air-dry Good technique requires that the puncture site not

be repalpated If absolutely necessary, the fi ngertip of the glove must be prepped in the same manner as the venipunc-ture site

8 Apply the tourniquet, being very careful not to touch the ture site with the tourniquet

9 Perform the venipuncture and draw the appropriate volume of blood (Figure 7-2C)

with gauze

entered the syringe prior to injection This allows the ate volume of blood to be added to the bottle

blood If too much blood is added, clotting may occur, impairing the recovery of bacteria

16 Specimen requirements: 8 to 10 mL of blood should be injected into each culture vial Fill the anaerobic bottle fi rst If using a winged blood collection set, fi ll the aerobic bottle fi rst The air in the tubing will prevent the growth of anaerobic organisms Use

a safety transfer device that pierces the stoppers of the blood culture bottles If a fungus culture is ordered, 8 to 10 mL of blood is injected into the fungus culture vial

for collection and the number of the sample, time collected, and phlebotomist’s initials

ORAL GLUCOSE TOLERANCE TESTING

Patients with mild or diet-controlled diabetes may have fasting blood cose levels within the normal range, but be unable to produce suffi cient

blood glucose rises to abnormally high levels and the return to normal is delayed The glucose tolerance test detects a patient’s decreased tolerance for glucose, and is most helpful in establishing a mild case of diabetes

The GTT is a timed test of blood and urine that determines the rate of removal of a concentrated dose of glucose from the bloodstream In the healthy person, the insulin response to an oral dose of glucose is almost immediate, peaking in 30–60 minutes and returning to normal within

3 hours Testing is usually done in the morning after an overnight fast

Patient Preparation

1 The patient should be placed on a diet containing 1.75 grams of carbohydrate per kilogram of body weight for 3 days preceding the test If carbohydrate intake has been too low preceding the test, a false diabetic-type curve may result Drugs that may infl u-ence the test should be discontinued for 3 days before the test

Such drugs may include hormones, salicylates, diuretic agents, and hypoglycemic agents

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2 The test should be performed in the morning, and the patient must abstain from eating or drinking anything except water for

8 hours prior to the test The patient must remain fasting for the duration of the test

3 The patient should remain at rest during the test and refrain from smoking or chewing gum

iden-“Fasting” on the urine and blood samples

2 Perform a rapid glucose test on the fasting sample If the result

is >140 mg/dL, delay proceeding with the test until a pathologist has been consulted

3 Give the patient a glucose loading dose based on the following:

a Nonpregnant females and males over 100 lbs: 75 grams glucose

b Pregnant females: 100 grams glucose

c Patients under 100 lbs: 1.75 grams glucose per kilogram body weight

4 Blood and urine specimens are collected at 1 hour, 1½ hour,

2 hours, 3 hours, etc, depending upon the physician order glucose ingestion The glucose dose should be ingested within

post-5 minutes

BLEEDING TIME TEST

Bleeding time measures the primary phase of hemostasis (the interaction

of the platelet with the blood vessel wall and the formation of the static plug) It is a test that involves the making of a standardized wound or incision and timing the process of clot formation The bleeding time test detects vascular abnormalities and detects platelet abnormalities or defi -ciencies A platelet count should be ordered before starting the bleeding

hemo-time test The bleeding hemo-time test should not be done when the platelet count is below 100,000 per cubic millimeter There are three methods of bleeding time tests: Duke, Ivy, and Template or Surgicutt The following procedure is for the Template Bleeding Time Please refer to Figure 7-3

Figure 7-3 bleeding time procedure (A) Prep forearm site with alcohol (B) Place blood pressure cuff on

patient’s arm (C) Remove blade from package (D) Remove safety clip (E) Rest device on prepped site Push

the trigger, and start stopwatch (F) Immediately remove the device from the patient’s forearm and dispose of

device into sharps container (G) Blot the blood with fi lter paper at 30-second intervals (H) Continue to wick

the blood every 30 seconds until no blood is visible (I) Bandage the incision with a butterfl y bandage.

The sterile disposable device used to make a uniform incision is a loaded blade contained in a plastic housing When triggered on the fore-arm or leg, the device makes one incision, 5mm long by 1mm deep

spring-Simultaneously, a stopwatch is started The blood from the incision is ted at 30-second intervals The time required for the bleeding to cease is estimated to the nearest half minute

Filter paperAlcohol swabButterfl y bandageGloves

GauzeBandage

Procedure:

1 Identify the patient using appropriate protocol

2 Explain the procedure to the patient

3 Obtain a drug history before the test is preformed

4 Aspirin and aspirin-containing products will interfere with the test The patient must be asked whether he has taken any such products within the last 7 days Record all drugs taken on the patient history form

5 Position the patient with forearm facing upward on a support

Select an area of the forearm distal to the antecubital fossa ing care to avoid surface veins, scars, and bruises

6 Cleanse with an alcohol swab and allow the area to completely dry, at least 10 seconds (Figure 7-3A) If the patient has marked hair, lightly shave the area Do not perform the test on an arm that is edematous, has an IV, or is on the side of a mastectomy

7 Place the pressure cuff on the patient’s upper arm, over the tery at the level of the heart (Figure 7-3B) Infl ate the pressure cuff to 40 mm Hg Hold the pressure for the duration of the test

8 Place the unpackaged blade fi rmly on the forearm, being ful not to press down on the arm Press the trigger to release the blade See Figures 7-3C through F

9 Dispose of the blade into a sharps container

made

disturb the wound (Figure 7-3G)

wick blood (Figure 7-3H)

procedure

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15 Record the time in minutes and half minutes (example:

5.5 minutes)

Cover with gauze and tape over gauze Do not clean the wound with alcohol, which would remove the platelet plug

Normal range: 3–9 minutes

SUMMARY

It is important for phlebotomists to know the collection procedures required for unique tests such as newborn screening, blood cultures, oral glucose tolerance testing, and bleeding times Correct collection of these tests ensures accurate test results necessary for physician diagnosis

REVIEW ACTIVITIES

1 Blood cultures are used to rule out or confi rm

2 The purpose of newborn screening is to

3 The two tests required in all states are

6 A glucose tolerance test requires and

to be collected from the patient at what intervals?

8 The normal value test range for a bleeding time is minutes

DISCUSSION QUESTIONS

1 What factors may cause erroneous test results for blood cultures?

2 What is the purpose of testing for hypothyroidism in newborns?

3 Why is a medication history important in performing a bleeding time test?

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After studying this unit, it is the responsibility of the learner to be able to:

1 Describe how basic venipuncture techniques may be enhanced to accommodate the needs of infants

2 List the different blood collection techniques used to collect specimens from infants

3 State the different needs of children as they grow from infancy and describe how to adjust your approach to them when collecting blood samples

4 Describe the various physical changes the elderly experience as they advance into later stages of their life

5 Give examples of how the phlebotomist may adjust their interactions with the elderly to meet the needs of the patient

6 Describe how venipuncture in the hand differs from a venipuncture in the antecubital fossa

7 List the different types of vascular access lines

8 Describe the collection of blood samples from vascular access lines

Special Considerations

“Care more for the

individual patient than

for the special features

of the disease.”

—Osler8

obtaining blood samples, administering drugs, supplying nutrition, and transfusing blood products

dorsal relating to the back side

heparin a drug used as an anticoagulant

patient-focused care an approach to health care

in which services are simplifi ed, decentralized, and placed close to the patient

patient care

saline a solution containing sodium chloride used as a plasma substitute and a means to correct electrolyte imbalances

systolic contraction of the heart, the upper number of a blood pressure reading

tetany a disorder characterized by muscular twitching, cramps, and convulsions

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hlebotomists must be able to apply routine venipuncture cedures to special situations These situations require the abil-ity to adjust to the needs of a particular patient There is a need to understand the age-specifi c uniqueness of infants, chil-dren, and the elderly Occasionally, patients have special needs requiring special collection procedures Central access lines and point-of-care testing require collection procedures other than routine venipuncture.

pro-PEDIATRIC BLOOD COLLECTION

Both venipuncture and skin puncture techniques are used to collect blood specimens from children The techniques are basically the same as those used to collect specimens from adults However, children are not min-iature versions of adults They are unique individuals, and they require special consideration when the phlebotomist is collecting blood samples

These special considerations involve collection techniques as well as ferent interaction requirements for the phlebotomist By performing the task well, the phlebotomist can help give children a positive image of health care workers

dif-Infants

Taking blood from infants is often intimidating to the phlebotomist ever, experience and confi dence will make the phlebotomist as comfort-able performing a venipuncture on an infant as on an adult Infants have many needs, especially when they are ill The phlebotomist can best sat-isfy those needs by observing infants’ behavior and handling them in a soothing and reassuring manner Different infants have different tempera-ments, and, of course, sick babies may respond in a very negative fashion

How-Research has found that babies can be classifi ed as having one of three basic temperaments:

Diffi cult—showing unpredictable patterns of response, intense

While a phlebotomist may naturally be inclined to speak more gently

to “easy” babies and to give them soothing touches, every effort must be made to give all babies their share of attention Use a soft, soothing tone

of voice to talk to the infant patient Take time to softly stroke the infant’s arm, hand, or foot before performing the puncture Even though the infant is unable to communicate verbally, use your voice to make every effort to express feelings of warmth and concern to the child Infants are human beings worthy of your full respect

Blood samples may be collected from the infant by capillary puncture

of the heel or by venipuncture if a vein is apparent If venipuncture will

be used, the dorsal hand vein technique is favorable, because it decreases hemolysis, decreases dilution due to interstitial fl uid, decreases the number

of punctures required, and decreases agitation of the infant (Jamieson &

Hurwitz, 1994) To perform a venipuncture of the dorsal hand vein (a vein

on the back of the hand), the procedure is almost the same as for a routine venipuncture, with a few exceptions

P R O C E D U R E

P R O C E D U R E D o r s a l H a n d V e i n V e n i p u n c t u re

1 After putting on gloves, place the baby’s wrist between your middle and index fi ngers and apply slight pressure The pressure acts as a tourniquet to allow venous fi lling (Figure 8-1)

2 Lightly stroke the back of the infant’s hand to help you see and palpate veins Select only visible veins to avoid deep puncture

Figure 8-1 Dorsal hand vein collection.

3 After selecting a vein, release the pressure of your index and middle

fi ngers This allows circulation to resume while you prep the site

4 Cleanse the puncture site with alcohol by wiping in a circular manner, from the center to the outside

5 Allow the alcohol to dry

6 Reapply pressure to act as a tourniquet

7 Using a 23-gauge needle with a translucent hub, with the bevel facing up, align the needle at approximately a 10-degree angle

to the skin’s surface and in a direct line with the vein The ment helps to prevent penetration through the vein

8 Slowly puncture the skin and the vein A rapid puncture may cause penetration through the vein

9 As soon as blood appears in the hub, stop advancing the needle

penetrating through the vein

pressure to increase blood fl ow You may also try rotating the needle slightly

until bleeding stops

of other tasks The phlebotomist can be creative in allowing children to participate, so long as safety is kept in mind

Children tend to regress, however, when they become ill or they fi nd themselves in stressful situations Some children may regress back into infant behavior This is normal, and the phlebotomist should not be harsh

or chide children for not acting their age Instead, a more positive approach may be taken to encourage age-appropriate behavior Describe the behav-ior you would like to see, and ask the child to help in “getting the job done.”

Talk to the child directly instead of talking “about” the child to the parent (Figure 8-2) Recognizing the uniqueness of the child as an individual, and understanding that the child is also a product of a developmental phase, will help you produce a positive experience for the child and the parent

Often, especially when a child has a chronic or lengthy illness, ers and sisters may be present when blood is drawn, whether the child

broth-is an outpatient or an inpatient Brothers and sbroth-isters can be very close to the young patient and may feel excluded from that closeness when health care procedures are performed Be alert to the presence and attitude of siblings Include the siblings in the conversation Ask them to assist with some small task, and give them the same “reward” stickers or toys that you give the young patient This will help you and the family to work together

to serve the best interests of the child who is ill

ELDERLY BLOOD COLLECTION

Geriatrics is a medical specialty concerned with the prevention, diagnosis, and treatment of diseases in the elderly Geriatric patients need special considerations, just as infants and children do The effects of aging vary from one patient to another However, we can make certain assumptions

Figure 8-2 Pediatric venipuncture.

concerning the physiological aspects of elderly patients Phlebotomists need to know these physiological considerations so that they can perform blood collection procedures more appropriately.

Several changes take place in the human body as it ages Hearing and vision decline, muscle strength lessens, and soft tissues such as skin and blood vessels become less fl exible

Hearing Loss

The phlebotomist may need to speak slightly louder to an elderly patient

To test for hearing, ask, in a normal voice volume, the patient’s name If she or he does not appear to hear, you will know you must raise your voice slightly when speaking

Vision Loss

The phlebotomist may need to assist with reading of information The patient may not be able to see directional signs The phlebotomist should

be alert to helping elderly patients fi nd different hospital departments

Muscle Strength and Flexibility

The phlebotomist needs to practice patience when asking a patient to physically respond to requests The elderly may need assistance in sit-ting up, adjusting arms for a venipuncture, walking to a drawing chair, and so on

Skin and Blood Vessels

The phlebotomist must carefully observe the character of the vein prior

to drawing a specimen You may wish to use a smaller gauge needle, a butterfl y setup, and so on Elderly patients often have veins that collapse from the vacuum of the collection tube Their skin is often fragile The use

of paper tape is recommended, or perhaps no tape at all Taking time to apply pressure to the venipuncture site may be more appropriate

Intelligence

A myth of aging is that intelligence diminishes with age Studies show that there is relatively little decline in mental ability in healthy people at least

up to age 70 However, studies also show that some older people may fi nd

it diffi cult to deal with many stimuli at once In a busy outpatient ratory, the phlebotomist must demonstrate patience and give the older patient time to respond to directions There is also the potential for mem-ory problems The phlebotomist may need to repeat instructions

labo-Family Members

As the elderly become more dependent upon assistance from family members,

be sure to include family members in instructions and directions Explain

to family members what is involved in the venipuncture, fasting ments, and any other special instructions Ask family members if they have any questions concerning the venipuncture and laboratory requirements

require-ALTERNATIVE VENIPUNCTURE SITES

Whenever the phlebotomist is faced with the inability to fi nd a suitable venipuncture site in the antecubital area, an alternative venipuncture site must be located Venipuncture sites other than the antecubital fossa may include the dorsal side of the hand and wrist, the dorsal side of the ankle, and the dorsal side of the foot Please refer to Figure 8-3 and Figure 8-4

Dorsal digital veins

Superficial dorsal veins

Dorsal venous arch Basillic veins Cephallic veins

Figure 8-3 Dorsal hand veins.

Ankles and feet should be considered as a last resort A physician’s order must be obtained before puncturing a vein in the foot or ankle Leg veins are very poor options due to the depth of the veins and the tough-ness of the skin If the ankles and feet should be the choice site of a veni-puncture, use a winged collection set with a syringe

The dorsal site of the hand is often a good site for venipuncture ing the venipuncture technique will result in a successful puncture The following adjustments from a routine venipuncture should include:

Adjust-The veins of the hand are more superfi cial than the veins in the

Anchor the veins very securely The top of the hand has less

•

fatty tissue than the antecubital fossa This means that the veins may roll away from the needle more easily than antecubital veins

Use a 23-gauge winged needle with a syringe Use of the evacuated

•

collection set will collapse the vein

Apply adequate pressure to the puncture site once the needle has

VASCULAR ACCESS LINES

to administer drugs, fluids, and nutritional solutions; to make blood transfusions; and to obtain blood specimens for laboratory testing Periph-erally inserted central catheters (PICC), Hickman and Groshong Lines,

samples for laboratory testing The tunneled catheter is inserted into a vein at the neck, chest, or groin, and tunneled to an exit site underneath the skin The exit site is usually located in the chest The implanted port is similar to a tunneled catheter except that it is left entirely under the skin

The PICC is a CVC inserted into a vein in the arm instead of the neck, chest, or groin Health care facilities have their own individual policies and procedures for obtaining blood specimens from the venous catheter

Phlebotomists or other health care personnel must have received special training before being allowed to utilize the catheters

A PICC is placed into the cephalic or basilic vein in the antecubital

•

fossa The tip of the line is threaded to the superior vena cava PICCs can be used for weeks to months Before obtaining a blood specimen,

fl ush with 5 cc saline The line must be cleared by drawing 5 mL

of discard blood Obtain the blood sample, and fl ush the line with

5 cc saline followed with 5 cc heparin

Hickman Line is silicon tubing placed surgically into a vein with

•

the end tunneling through subcutaneous tissue to the exit site in the chest The tip of the catheter ends in the superior vena cava

The catheter is for long-term use The Hickman catheter requires

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a clamp to make sure the valve is closed It is inserted into the jugular vein and then tunneled under the skin to the exit site When

a blood sample is being obtained, the line is fi rst fl ushed with 5 cc saline Discard 5 mL of blood Obtain the blood sample and fl ush with 10 mL heparin saline Sterile technique is extremely important,

as the line may serve as an entry for pathogenic organisms

A Groshong Line is the same type of catheter as the Hickman

•

Line However, the fl ush does not contain heparin, and the discard blood should be 10 cc rather than 5 cc The Groshong does not need a clamp It has a three-way valve that prevents blood from backing up into the catheter The valve opens outward during infu-sion, and opens inward during blood aspiration When it is not being accessed, the valve remains closed

Heparin or saline locks are winged infusion sets that can be left

•

in the vein for up to 48 hours They are placed for the purpose of short-term use They are often used by the laboratory for stimu-lation studies such as a cortisol stimulation test The catheter is

fl ushed with heparinized saline fl ush after each use

Blood tests utilizing blood samples collected from central venous access (CVA) lines require special consideration Coagulation studies should not use blood from CVAs However, if absolutely necessary, 20 mL

of discard blood must be obtained The source of the blood must be mented Please refer to Figure 8-5 and Figure 8-6

docu-Figure 8-5 Heparin lock.

Figure 8-6 Placement of Groshong ® Catheter.

Vein

Exit site from skin

Catheter

Cuff

Tunnel under skin

Heart

Entrance site into vein

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3 Apply a cool cloth to the patient’s head.

4 Reassure the patient

5 Instruct the patient to breathe slowly

6 Document the incident

Fainting

Symptoms include moderate progression of the preceding symptoms,

to include periods of unconsciousness, rapid and shallow respiration or hyperventilation, slow pulse, and hypotension with systolicpressure as low as 60 mm Hg

3 Loosen the patient’s clothing

4 Document the incident

Fainting with Complications

Symptoms include progression of fainting symptoms, including untary body movements, deeper loss of consciousness, and generalized state of tetany, rhythmic muscular contractions, raspy breathing, and cessation of muscle activity

invol-Treatment:

1 Notify the pathologist immediately

2 Follow the treatment for fainting

3 Document the incident

Hematoma

There is bruising at the venipuncture site

Treatment:

1 Remove and dispose of needle

2 Apply pressure for 5 minutes

3 Cold packs may be applied to reduce bruising and pain ately after hematoma forms

immedi-SPECIAL PATIENT CONSIDERATIONS

1 You may give the patient the names of any tests ordered Do not attempt to explain why the physician ordered the tests

2 Refer the patient to the physician for further explanation

Patient Refuses Blood Draw

1 Do not argue with the patient

2 Explain that the physician ordered the test, and explain any tinent time considerations (if the test is a stat or timed test)

3 Ask if the patient still wishes to refuse the test

4 If the patient refuses, report the objections to the nurse or sician, as appropriate

5 Document the refusal in the laboratory

Physician Is with the Patient

In a hospital setting, if the physician is with the patient when you arrive to perform a blood draw, ask the physician if the specimen needs to be col-lected at that time or if you should return later The physician always has priority with the patient

PATIENT-FOCUSED CARE AND POINT-OF-CARE TESTING Patient-Focused Care

New opportunities for job enrichment are becoming available to omists In the next several years, phlebotomists may have an opportunity

phlebot-to become part of the patient-focused care concept that has been tiated in several hospitals throughout the country This concept implies expanded roles for phlebotomists and other health care workers

ini-Hospitals have begun to reassess their traditional approaches to viding health care They need to enhance the quality of care while com-bining it with more cost-effective practices Many recent studies show that the most obvious contributor to high costs and ineffi ciency is hospitals’

pro-poor organizational structure, which can result in multiple management layers, too many specialized job descriptions, communication problems, delays in performing procedures, and continuous disruptions for patients

by a multitude of staff members from specialized units

Greater continuity of care and reduced costs will be goals that tals actively pursue through reorganization Patient-focused care is seen

hospi-Copyright 2010 Cengage Learning All Rights Reserved May not be copied, scanned, or duplicated, in whole or in part Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).